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HomeMy WebLinkAboutBLDG-23-002353 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 31,2022 PERMIT# BLDG-23-002353 JOBSITE ADDRESS 33 CAPT DANIEL RD OWNER'S NAME BRADY MICHAEL G OWNER ADDRESS 33 CAPT DANIEL RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE GENERATOR 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST _ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Larry Gemma LICENSE# 25142 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LARRY T GEMMA ADDRESS. 1 WELLINGTON RD, CITY LINCOLN STATE RI ZIP 028654411 TEL FAX CELL EMAIL permitsta7,Qemplumbinp.com • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK HE CITY Q As.ou7y MA DATE JO- ,2.2, PERMIT# 2-3— 23 S'3 JOBSITEADDRESS 33 CAta7AIA/ PA Ad RQJWNER'SNAME eitiAnd ALEoc SoAd G7 OWNER ADDRESS 3 3 CAP7A/^d D/4ti/EL RD. . TE4/7-997 G(o/9 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: . _ REPLACEMENT: PLANS SUBMITTED: YES NO ✓ APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR / GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER REPAIR GAS LEAK AND TEST INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ✓NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are/ and accurat to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cpmpliance waken/Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L/ / < aIC:61l� . PLUMBER-GASFITTER NAME LARRY GEMMA LICENSE#/oZ979 �-`/ SIGNATURE MP ✓ MGF JP JGF LPGI CORPORATION V# 3 6 yp PARTNc z HIP # LLC # COMPANY NAME: GEM PLUMBING&HEATING ADDRESS 1 WELLINGTON ROAD CITY LINCOLN STATE RI ZIP 02865 TEL 401-598-6125 FAX CELL EMAIL PERMITS@GEMPLUMBING.COM